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Our goal is to educate, encourage, and entertain as we provide general pediatric advice. However, please understand that Two Peds in a Pod® does not replace your relationship with your pediatric health care provider. We encourage parents to address specific questions about their children’s health with their pediatrician and not to delay seeking this advice because of content learned from Two Peds in a Pod®. Please know also that while our anecdotes are based on real patients, identifying features have been changed in order to protect patient confidentiality.

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Category: 2. Babies

10. The ability to attract swarms of women if you walk in the park or the grocery store with your infant.

9. Tolerance of temperature extremes at the skating rink or on the ball field.

8. Not being completely grossed out by spit up on your nicely pressed shirt.

7. The ability to sit patiently through a 3 hour ballet recital, school music concert or graduation.

6. The ability to sit patiently through an endless one hour television show featuring some sort of dancing and singing animal and then to stand in an hour long line to buy the stuffed toy version of the animal.

5. The skill to coach teams for which you last played the sport twenty years ago.

4. The ability to swing a child, “again!”, “again!”, and “again!”

3. The ability not only to get through a day after one (or many) completely interrupted night’s sleep, but to wake up in the morning having forgotten about the interruptions.

2. An ability to seize the moment and create great memories for your child: you ignore the dishes, the garbage, and the dirty bathrooms in lieu of an impromptu wrestling match.

1. Ability to love more than you ever thought possible, and the ability (finally) to understand just how much your father loves you.

Ten years ago I watched a very sick, feverish toddler arch his back on my exam table while a high pitched screech weakly escaped his mouth as I tried to examine him. Attempts by his mother to cradle him in her arms only resulted in more pain.

The diagnosis –– bacterial meningitis, puss in the spinal cord and around the brain.

A few months after I saw that toddler with meningitis, a vaccine against Strep pneumonia, under the brand name Prevnar-7, entered the market. I often wonder how outcomes would have differed for that toddler if the vaccine had been released earlier.

In addition to causing bacterial meningitis in children, this pneumococcal germ is also responsible for other forms of invasive disease such as pneumonia and overwhelming infection in the blood (sepsis). After Prevnar-7 entered the market in 2000, the number of children contracting invasive pneumococcal disease dropped by 76 percent. This decrease was seen in children under age five years, the most common age group for contracting pneumococcal disease. Vaccines at work!

The original Prevnar-7 offered protection against 7 types of the pneumococcal germ. But other types which weren’t targeted by Prevnar continued to cause infections. A new vaccine called Prevnar-13 offers protection against six additional types.

How does the release of the new Prevnar-13 affect your child? Recently, the American Academy of Pediatrics released its immunization recommendations:

–If your child has never been immunized against Pneumococcus, he will receive Prevnar-13 instead of Prevnar-7 on the same schedule as in the past. The series of four doses total are given at two months of age, four months, six months, and lastly a booster dose at 12-15 months of age.
–If your child is under five years old but has completed the full Prevnar-7 schedule, he will need at least one dose of Prevnar-13 to be fully protected.
–If your child is in the middle of the Prevnar series, he will likely complete the series with Prevnar-13.
–Children from 6 years to 18 years of age who are at very high risk for complications (e.g., children with sickle cell anemia and cochlear implants) may consider at least one dose of Prevnar-13 along with their usual “high risk” pneumovax 23 vaccine.

At this point there aren’t any recommendations to immunize non-high-risk children after five years of age because for most children, the risk of contracting life-threatening illness from this germ dramatically decreases after age five.

There’s more protection out there against more streptococcal pneumonia. Go get it!

For the full AAP recommendations see the online version of the AAP Policy Statement May 24, 1010 at www.pediatrics.org.

See also: Center for Disease Control March 12, 2010 Mobidity and Mortality Weekly Report for information about the impact of Prevnar on invasive pneumococcal disease.

One parental job you probably did not anticipate is the upkeep of rapidly growing finger and toe nails. Questions first time parents often ask me include: Should I use clippers or scissors? How do I avoid accidently nicking the skin? How often should I trim? The only question I haven’t heard so far is: Should the tips be rounded or squared?

When your newborn fingers her face, even her soft finger nails can cause scratches. Yes, newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to the underlying skin. I recommend using an emery board or nail file for the first weeks of nail trimming. This method is unlikely to go awry and is effective. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first 3 months at a rate of about one ounce per day and they grow in length at a rate of about an inch per month. Their finger nails grow as rapidly as the rest of the body and therefore need trims as often as twice a week. Toe nails grow quickly as well but because they do not cause self-injury, infants tend to be okay with less frequent trimming.

Once the nails are easy to “grab,” advance to using scissors or clippers. I honestly don’t believe either method is superior to the other. The method I used was to hold my baby on my lap facing out and then gently press the skin down from his nails and clip or cut carefully.

Unfortunately, no matter how careful you are, it is possible to hurt your child while cutting his nails. I remember injuring one of my twins when he was a few months old. Picture a benign tiny paper cut that seems to cause a disproportionate amount of bleeding. He wasn’t even all that upset, but…oh, the guilt I felt! If you accidentally nick your child, wash the cut with soap and running water and apply pressure for a few minutes with a clean washcloth to stop the bleeding. Once the bleeding stops, band aids are not necessary and can actually be a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing kids heal wounds rapidly.

I think it is a good idea to trim nails while babies are awake so that they get used to the feeling of a “home manicure.” This practice can prevent the later toddler meltdowns over nail trimming. However, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet trim we must! Try clipping an uncooperative toddler’s nails while she is sleeping. If your toddler sleeps lightly, then you may have to time your manicure/pedicure for when another adult caregiver is home with you. One adult holds the hand/foot or distracts the toddler with singing, book reading, or watching a soothing video together (Elmo to the rescue once again!). The other trims the nails.

So, now with the birth of your child you have added a new title – “Master Manicurist” of your home. This job does become more glamorous when your child is old enough to ask for nail polish. Until then, happy nail trimming!

We all can picture our babies chewing on their fingers and toys and drooling before getting their first tooth. But what other symptoms do incoming primary teeth cause?

Nearly everything in the past has been blamed on teething, including seizures, meningitis, and tetanus. According to an article in Pediatrics in Review (April 2009), teething was listed as the official cause of death in about five thousand infants in England in the early 1800s. In France from 1600 to 1900, fifty percent of all infant deaths were blamed on teething!

Despite scientific evidence to the contrary, people still blame teething for numerous maladies.

Here are symptoms which are NOT caused by teething that parents should be aware of:

·Teething does not cause fever over 101 degrees F. Fever of this height or higher indicates infection somewhere. Maybe a simple viral infection such as a cold, or a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever over 101 F is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs.

·Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.

·Teething does not cause a cough severe enough to cause increased work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never have breathing problems or a severe cough as a result of teething. Instead, suspect a cough virus or other causes of cough such as asthma.

·Teething does not cause pain severe enough to cause a change in mental state.

Some children get crankier as their teeth erupt and cause their gums to swell and redden. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by his or her health care provider.

Just from a logic standpoint, if teething causes symptoms as babies get their primary teeth, shouldn’t incoming permanent teeth cause the same symptoms? Yet I’ve never heard a parent blame teething for a runny nose, rash, cough, fever, or general bad mood in an eight, nine, or ten year old child who is growing permanent teeth.

Maybe these parents are too busy bemoaning the cost of early orthodontal work.

When the Tin Man was a child in Oz, I’m sure his pediatrician never told his parents, “Has anyone ever said your child has a heart murmur? I hear one today.”

I know that when I tell parents about a heart murmur in their child, their hearts skip and jump. But not all heart murmurs are bad.

A heart murmur is an extra sound that we pediatricians hear when we listen to a child’s heart with a stethoscope. A normal heart beat sounds like this: “lub, dub. lub, dub. lub, dub.” A heart murmur adds a whooshing sound. So what we hear instead is “lub, whoosh, dub” or “lub, dub, whoosh.”

The “whoosh” is usually caused by blood flowing through a relatively narrow opening somewhere in or around the heart. Think of your blood vessels and heart like a garden hose. If you run the water (blood) very hard, or put a kink or cut a hole in the hose, the whoosh of the water grows louder in those locations.

Heart murmurs signal different issues at different ages. In a newborn, some types of heart murmurs are expected. Normal newborn hearts contain extra holes that close up after the first hours or days of birth. One type of murmur occurs as the infant draws in his first breath and holes in the heart, present inside the womb, begin to seal. As the holes get narrower, we sometimes hear the “whoosh” of blood as it flows through the narrowing opening. Then these holes close completely and the murmur goes away.

However, some murmurs in infancy signal “extra holes” in the heart. As pediatricians we experience our own heart palpitations when moms want to leave the hospital early with their infants who are less than 48 hours old. We worry because many infants who have abnormal hearts may not develop their abnormal heart murmurs and other signs of heart failure until the day after birth.

Preschool and early school age children often develop “innocent” heart murmurs. “Innocent” implies that extra blood flows through their hearts, but the hearts are structurally normal. These murmurs are fairly common and can run in families. However, there are heart problems which do not surface until this age. For this reason, remember to schedule those yearly well child checkups.

For teens, during the pre participation sports physical, pediatricians listen carefully for a murmur that may indicate that an over grown heart muscle has developed.

Again, holes are not the only culprit behind a murmur. The whoosh sound can also arise when a person is anemic and blood flows faster than normal. In anemic kids, the blood flows faster because it lacks enough oxygen-carrying red blood cells and the heart needs to move blood faster in order to supply oxygen to the body. The most common cause for anemia is a lack of sufficient iron intake. Subsequently, we hear these flow murmurs in children whose diets lack iron, in teenagers who are growing rapidly and quickly use up their iron stores, and in girls who bleed too much at each period. Replenishing the iron level makes a heart murmur from anemia go away.

Even a simple fever (see our earlier blog posts to learn more about fevers) can cause a heart murmur on physical exam. The murmur goes away when the fever goes away.

Pediatric health care providers can often distinguish between “innocent” heart murmurs and not-so- innocent heart murmurs by the sound of the murmur itself (not all “whooshes” sound alike). If any question exists, your child will be referred for more testing, which could include a chest x-ray, an EKG (electrocardiogram), and ECHO (echocardiogram, or ultrasound of the heart) or evaluation by a pediatric cardiologist.

If your child’s pediatrician tells you that your child has a heart murmur, “take heart”. Many times a murmur comes and goes or just becomes part of your child’s baseline physical exam. Even if your child has a serious heart problem, most cases respond well to medication, surgery, or both. While not all heart problems cause heart murmurs, and while not all murmurs signal heart problems, the presence of a heart murmur in a child can signal that your child needs further testing.

Unless, of course, your child is the Tin Man. In this case, extra sounds indicate that your child needs more oil!

As I pack for an upcoming family vacation, I am reminded of the numerous questions over the years that parents have asked me about traveling with children. Often they ask, what is the best way to travel that will allow everyone to enjoy the vacation?

Ha,ha, I think to myself.The real answer is to hire a sitter or enlist grandparents to babysit and leave the kids at home. My husband and I always refer to family vacations as “family displacements.”

No, really, family vacations are wonderful experiences as long as you hold realistic expectations. First you have to get there.

Easier said than done.

When traveling by air, parents wonder if they should bring a car seat for the plane. Young children who sit in a car seat in the car should sit in a car seat in an airplane. Unfortunately, not all car seats fit into the airplane seat properly. The best advice I can give is to bring your car seat and make an attempt to fit it properly. If it doesn’t fit properly, you will still need it for the car ride from the airport after you arrive at your destination. Not all car rental facilities provide car seats.

Another question I am frequently asked about long plane rides is “Should I give my child Benadryl (diphenhydramine) so he/she will sleep through the flight?” Unfortunately, Benadryl’s reliability as a sleep aid is spotty at best. Most kids get sleepy, but the excitement of an airplane ride mixed in with a “drugged” feeling can result in an ornery, irritable child who is difficult to console. I advise against this practice. On the other hand, Benadryl can help motion sickness and is shorter acting than other motion sickness medications.

Ear pain during an airplane’s descent is also a common worry. Yes, it is true that ears tend to “pop” during the landing as the air pressure changes with altitude. Some young children (and their parents) find this sensation very unpleasant. However, most babies are lulled to sleep by the noise and vibration of an airplane and are unaffected. If your child is safely in a car seat, I do not advise taking him out of it to breastfeed during landing. Offer a pacifier if you feel he needs to suck/swallow during the landing, and offer an older child a snack so she can swallow and equalize ear pressure if she seems uncomfortable during the landing.

Speaking of food, try to carry healthy snacks rather than junk food when traveling. Staying away from excessively salty or sweet food will cut down on thirst. Also, keep feeding times similar to home schedules in order to prevent toddler meltdowns.

Remember that young children hate to wait for ANYTHING and that includes getting to your destination. Bring along distractions that are simple and can be used in multiple ways. For example, paper and crayons or pencils can be used for: coloring, drawing, word games, origami, tic-tac-toe, math games, etc.

When traveling internationally, check the Center for Disease Control website www.cdc.gov for the latest health advisories for your travel destination. Do your research several weeks in advance because some recommended vaccines are available only through travel clinics. Also, some forms of malaria prevention medicine need to be started a week prior to travel.

Please refer to our “Happy, Healthy Holiday” blog post from 12/10/2009 for further information about keeping kids on more even keel during vacations. In general, attempt to keep eating and sleeping routines as similar to home as possible. Also remember to wash hands often to prevent illness during travel. Finally, locate a pediatrician or child friendly hospital ahead of time in case illness does strike. Unfortunately, most illnesses cannot be diagnosed by your child’s health care provider over the phone.

While traveling with young children can seem daunting, the memories you create for them are well worth the effort. And it DOES get easier as the kids get older. Now I can laugh at the image of my husband with two car seats slung over his back lugging a large diaper bag and a carry-on, leading my preschooler struggling with his own backpack filled with snacks and air plane distractions, while I am balancing two non-walking twin babies, one in each arm, as we all take our shoes off for the airplane security checkpoint.

Concerned parents ask me this question, and I am relieved to be able to tell them “NO.”

Amazingly, most of the autism/vaccine hoopla can be traced to one very small report.

In 1998 a doctor named Andrew Wakefield published a paper in a well respected British medical journal called The Lancet. He said that in his study of twelve children who were patients in a GI (Gastroenterology) clinic, eight of them had evidence of abnormal intestines and abnormal behavior that began after they received the MMR vaccine. He wondered if the combined MMR vaccine may have triggered abnormalities in the gut, allowing unspecified toxins to leak out from the gut, causing brain damage.

Unfortunately, this one small paper involving 12 children caused huge controversy about the safety of vaccines. Many parents lost confidence in the very vaccines that were so successful at protecting the lives of their children.They stopped vaccinating and caused the measles rate to increase. For evidence of this please see:

On February 6, 2010, The Lancet published a retraction of this paper because the study design was flawed and thus any conclusions cannot be reliable. Specifically, the UK General Medical Council’s Fitness to Practise Panel, after investigations, concluded that the children in the study were not “consecutively referred,” meaning that they were not “random samples” as stated in the paper.

In addition, the panel discovered that Dr. Wakefield did not have permission from any institutional review board (panels that review the ethics of research done on people) to perform the lumbar punctures, MRIs, EEGs, endoscopies, and intestinal biopsies that he conducted on the children whom he studied.

Despite the original study being flawed, a question about a connection between MMR and autism had been raised. In the years since 1998, scientists performed subsequent studies to see if the MMR vaccine might have a link to autism. No association was found. These studies involved thousands of children and showed that the rate of autism in vaccinated children is THE SAME as the rate of autism in unvaccinated children. To read these articles as well as the original article that caused the controversy, you can go to www.TheLancet.com and register to view the articles for free.

I urge all parents reading this blog post to speak with your child’s health care provider if you have ANY doubts about vaccinating your children. In addition, if you are going to conduct your own research on this subject on the Internet, I urge you to consult the following credible sites:

Vaccines save lives. Unfortunately, for those too young to be vaccinated, those who have immune system diseases, and those who do not receive immunizations, vaccine preventable diseases still can potentially cause severe illness and death.

My sister-in-law was startled when brown spots began to appear on her preschooler’s teeth. A trip to the dentist revealed that my nephew had eleven cavities, the result of constantly drinking juice as an infant and toddler. Unfortunately, time in the operating room was required to fill all the rotten spots. Today our guest blogger, Dr. Paria Hassouri, answers frequently asked questions on infant dental care. Starting care as an infant can prevent your child from ending up like my nephew with a mouthful of cavities. Dr. Hassouri is a board certified pediatrician who completed her training at the Cleveland Clinic Foundation. She has been in practice for seven years and is with Cedars Sinai Medical Group in Beverly Hills, California. She is currently writing abook about the experience of pediatrician moms across the United States. – Dr. Lai

When do I need to start brushing my baby’s teeth?

You should start brushing your baby’s teeth as soon as they come out. You can either use a clean moist washcloth or a soft baby toothbrush to do this. Before this point, many pediatricians advocate wiping your infant’s gums with a washcloth a couple times a day.

While plain water is enough to clean the teeth and gums, you can also use a small amount of fluoride-free toothpaste. Flossing should begin anytime there is tight contact between the teeth, particularly when the molars come in.

When will my baby get his/her first tooth?

While most babies will get their first tooth between 6 to 10 months, your baby may not get his/her first tooth until 15 to 18 months.

What is “baby bottle tooth decay” and how do I prevent it?

Baby bottle tooth decay is caused by frequent and long exposure of an infant’s teeth to liquids that contain sugar. The sugar penetrates the gums and affects the teeth even while they are below the surface. Sugar-containing drinks include milk and formula (even breastmilk), fruit juice, and other sweetened drinks. Putting a baby to bed for naps or at night with a bottle increases the risk. And again, remember that your baby does not need any juice.

When does my baby need to first see a dentist?

While the American Academy of Pediatric Dentistry recommends dental visits starting at age one, you can ask your pediatrician when he/she thinks that your baby should first see the dentist. If you are already following a good dental care regimen which includes brushing your baby’s teeth regularly and not letting your baby fall asleep with a bottle, your pediatrician may say that you can wait longer for the first dental visit.

What to I do if my baby dislikes or refuses to let me brush his/her teeth?

Even if your child resists brushing, it is still very important to brush the teeth twice a day. You can try brushing in front of a mirror or taking turns with your child. You can also try having your child hold a larger, thicker handled toothbrush while you use a thinner handled toothbrush to brush the teeth. In this way, the thicker toothbrush acts as a “door stop” that your child can bite on to keep his mouth open while you follow through with the thinner toothbrush. Finally, you can try blowing bubbles or singing a special song while you are brushing your child’s teeth. That way your child associates this special activity with tooth brushing; but keep in mind that this only works if you reserve the blowing bubbles or other special song for tooth brushing.

What should we do if we don’t have fluoride in our water ?

If your water does not contain fluoride, ask your pediatrician or dentist about fluoride supplements starting at six months old.

Autism is a disorder of communication. Autistic children have difficulty relating to other people. Many parents are concerned about autism and ask me questions about how to know that their child does NOT have autism.

Tools for autism screens exist for older toddlers. For example, the M-CHAT is a standard autism screening tool used as young as 16 months and can be downloaded for free: http://www.firstsigns.org/downloads/m-chat.PDF.One hallmark of autism is delayed speech. This sign makes autism difficult to diagnose before the age of one year because language development really takes off after a child’s first birthday.

Here are some communication milestones that occur during the first year of life. Problems attaining these milestones can be indicative of autism or other communication disorders such as hearing loss, vision loss, isolated language delay, or other developmental delays:

By six weeks of age, your baby should smile IN RESPONSE TO YOUR SMILE. This is not the phantom smile that you see as your baby is falling asleep or that gets attributed to gas. I mean, your baby should see you smile and smile back at your smile. Be aware that babies at this age will also smile at inanimate objects such as ceiling fans, and this is normal for young babies to do.

By 2 months of age, babies not only smile but also coo, meaning they produce vowel sounds such as “oooh” or “aaah” or “OH.” If your baby does not smile at you by their two month well baby check up visit or does not coo, discuss this delay with your child’s health care provider.

By four months of age, your baby should not only smile in response to you but also should be laughing or giggling OUT LOUD. Cooing also sounds more expressive (voice rises and falls or changes in pitch) as if your child is asking a question or exclaiming something.

Six-month-old babies make more noise, adding consonant sounds to say things like “Da” and “ma” or “ba.” They are even more expressive and seek out interactions with their parents. Parents should feel as if they are having “conversations” with their babies at this age: baby makes noise, parents mimic back the sound that their child just made, then baby mimics back the sound, like a back and forth conversation.

All nine month olds should know their name. Meaning, parents should be convinced that their baby looks over at them in response to their name being called. Baby-babble at this age, while it may not include actual words yet, should sound very much like the language that they are exposed to primarily, with intonation (varying voice pitch) as well. Babies at this age should also do things to see “what happens.” For example, they drop food off their high chairs and watch it fall, they bang toys together, shake toys, taste them, etc.

Babies at this age look toward their parents in new situations to see if things are ok. When I examine a nine month old in my office, I watch as the baby seeks out his parent as if to say, “Is it okay that this woman I don’t remember is touching me?” They follow as parents walk away from them, and they are delighted to be reunited. Peek-a-boo elicits loud laughter at this age. Be aware that at this age babies do flap their arms when excited or bang their heads with their hands or against the side of the crib when tired or upset; these “autistic-like” behaviors are in fact normal at this age.

By one year of age, children should be pointing at things that interest them. This very important social milestone shows that a child understands an abstract concept (I look beyond my finger to the object farther away) and also that the child is seeking social interaction (“Look at what I see/want, Mom!”).Many children will have at least one word that they use reliably at this age or will be able to answer questions such as “what does the dog say?” (child makes a dog sound). Even if they have no clear words, by their first birthday children should be vocalizing that they want something. Picture a child pointing to his cup that is on the kitchen counter and saying “AAH AAH!” and the parent correctly interpreting that her child wants his cup. Kids at this age also will find something, hold it up to show a parent or even give it to the parent, then take it back. Again, this demonstrates that a child is seeking out social interactions, a desire that autistic children do not demonstrate. It is also normal that at this age children have temper tantrums in response to seemingly small triggers such as being told “no.” Unlike in school-age children, difficulties with “anger management” are normal at age one year.

As an informal screen for autism, children below one year of age should be monitored for signs of delayed or abnormal development of social and communication skills. Home videos of children diagnosed with autism reveal that even before their first birthdays, many autistic children demonstrate abnormal social development that went unrecognized.

Following the above guides and discussing your child’s development at all well child care check-ups will help you to pick out “red flags” that can prompt closer attention and further work up if indicated.